Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission (Page 4 of 4) in pdf

13. Are there any witnesses to the alleged discriminatory incidents? If yes, please identify them below and tell us what

they will say. (Please attach additional pages if needed to complete your response)

Full Name

Job Title

Address & Phone Number

What do you believe this person will tell us?

A._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

B._______________________________________________________________________________________________________

_________________________________________________________________________________________________________

14. Have you filed a charge previously on this matter with the EEOC or another agency?

Yes

15. If you filed a complaint with another agency, provide the name of agency and the date of filing: __________________

_________________________________________________________________________________________________________

16. Have you sought help about this situation from a union, an attorney, or any other source?

Yes

Provide name of organization, name of person you spoke with and date of contact. Results, if any?

_________________________________________________________________________________________________________

Please check one of the boxes below to tell us what you would like us to do with the information you are providing on this

questionnaire. If you would like to file a charge of job discrimination, you must do so either within 180 days from the day you

knew about the discrimination, or within 300 days from the day you knew about the discrimination if the employer is located in

a place where a state or local government agency enforces laws similar to the EEOC’s laws. If you do not file a charge of

discrimination within the time limits, you will lose your rights. If you would like more information before filing a charge

or you have concerns about EEOC’s notifying the employer, union, or employment agency about your charge, you may

wish to check Box 1. If you want to file a charge, you should check Box 2.

BOX 1

I want to talk to an EEOC employee before deciding whether to file a charge. I understand that by checking this box,

I have not filed a charge with the EEOC. I also understand that I could lose my rights if I do not file a charge in time.

BOX 2

I want to file a charge of discrimination, and I authorize the EEOC to look into the discrimination I described above.

I understand that the EEOC must give the employer, union, or employment agency that I accuse of discrimination

information about the charge, including my name. I also understand that the EEOC can only accept charges of job

discrimination based on race, color, religion, sex, national origin, disability, age, genetic information, or retaliation for opposing

discrimination.

_______________________________________

____________________________________

Signature

Today’s Date

PRIVACY ACT STATEMENT: This form is covered by the Privacy Act of 1974: Public Law 93-579. Authority for requesting personal data and the uses thereof are:

1) FORM NUMBER/TITLE/DATE. EEOC Intake Questionnaire (9/20/08). 2) AUTHORITY. 42 U.S.C. § 2000e-5(b), 29 U.S.C. § 211, 29 U.S.C. § 626. 42 U.S.C. 12117(a)

3) PRINCIPAL PURPOSE. The purpose of this questionnaire is to solicit information about claims of employment discrimination, determine whether the EEOC has jurisdiction over those

claims, and provide charge filing counseling, as appropriate. Consistent with 29 CFR 1601.12(b) and 29 CFR 1626.8(c), this questionnaire may serve as a charge if it meets the elements of a

charge. 4) ROUTINE USES. EEOC may disclose information from this form to other state, local and federal agencies as appropriate or necessary to carry out the Commission's functions, or

if EEOC becomes aware of a civil or criminal law violation. EEOC may also disclose information to respondents in litigation, to congressional offices in response to inquiries from parties to the

charge, to disciplinary committees investigating complaints against attorneys representing the parties to the charge, or to federal agencies inquiring about hiring or security clearance matters.

5) WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL FOR NOT PROVIDING INFORMATION. Providing this information is voluntary but the

failure to do so may hamper the Commission's investigation of a charge. It is not mandatory that this form be used to provide the requested information.

November 2009

Intake Questionnaire Form - U.s. Equal Employment Opportunity Commission Page 4

Related Articles

Related forms

Related Categories